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Board Bomb: This Urine Drug Screen Changes Everything—Now What? · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:06
  back,
• 0:06
  my
• 0:06
  friends,
• 0:06
  to
• 0:07
  another
• 0:07
  episode
• 0:07
  of
• 0:07
  Pearls
• 0:08
  and
• 0:08
  Prep
• 0:08
  npz.
• 0:09
  Here,
• 0:09
  your
• 0:10
  preceptor
• 0:10
  in
• 0:10
  your
• 0:11
  pocket,
• 0:11
  your
• 0:11
  go
• 0:12
  to
• 0:12
  place
• 0:12
  for
• 0:13
  pearls
• 0:13
  that
• 0:13
  prep
• 0:14
  you
• 0:14
  to
• 0:14
  practice.
• 0:15
  Now
• 0:15
  back
• 0:16
  by
• 0:16
  popular
• 0:16
  demand,
• 0:17
  we
• 0:17
  have
• 0:17
  another
• 0:17
  board
• 0:18
  bomb
• 0:18
  for
• 0:19
  you
• 0:19
  today
• 0:19
  and
• 0:19
  this
• 0:19
  one
• 0:20
  is
• 0:20
  a
• 0:20
  doozy.
• 0:21
  We
• 0:21
  have
• 0:21
  a
• 0:21
  mock
• 0:22
  patient
• 0:22
  in
• 0:22
  your
• 0:22
  outpatient
• 0:23
  clinic.
• 0:24
  Her
• 0:24
  name
• 0:24
  is
• 0:24
  Bonnie.
• 0:25
  Okay.
• 0:26
  She's
• 0:26
  28.
• 0:27
  She's
• 0:27
  diagnosed
• 0:28
  with
• 0:28
  PTSD
• 0:28
  and
• 0:29
  major
• 0:29
  depressive
• 0:29
  disorder.
• 0:30
  It's
• 0:30
  a
• 0:31
  routine
• 0:31
  three
• 0:31
  month
• 0:31
  follow
• 0:32
  up.
• 0:32
  She's
• 0:33
  on
• 0:33
  trazodone,
• 0:34
  150
• 0:34
  milligrams.
• 0:35
  She's
• 0:35
  on
• 0:35
  bupropion
• 0:36
  XL,
• 0:36
  300
• 0:37
  milligrams.
• 0:38
  She's
• 0:38
  been
• 0:38
  on
• 0:38
  these
• 0:39
  meds
• 0:39
  for
• 0:39
  roughly
• 0:40
  six
• 0:40
  months
• 0:40
  total.
• 0:41
  She's
• 0:41
  had
• 0:41
  an
• 0:41
  excellent
• 0:42
  response.
• 0:42
  Her
• 0:43
  sleep
• 0:43
  is
• 0:43
  great.
• 0:44
  Her
• 0:44
  mood
• 0:44
  is
• 0:44
  stable.
• 0:45
  There's
• 0:45
  no
• 0:45
  si.
• 0:46
  She's
• 0:46
  back
• 0:46
  to
• 0:46
  work
• 0:47
  full
• 0:47
  time
• 0:47
  at
• 0:47
  the
• 0:47
  Dairy
• 0:48
  Queen.
• 0:48
  She
• 0:49
  denies
• 0:49
  any
• 0:49
  substance
• 0:50
  use.
• 0:50
  Her
• 0:50
  exam
• 0:51
  is
• 0:51
  unremarkable.
• 0:51
  She's
• 0:52
  bright,
• 0:52
  engaged.
• 0:53
  But
• 0:53
  you
• 0:54
  have
• 0:54
  noticed
• 0:54
  she
• 0:54
  lost
• 0:54
  about
• 0:55
  12
• 0:55
  pounds
• 0:56
  since
• 0:56
  her
• 0:56
  last
• 0:56
  visit.
• 0:57
  And
• 0:57
  she
• 0:57
  says
• 0:58
  she
• 0:58
  attributes
• 0:58
  this
• 0:59
  to
• 0:59
  finally
• 0:59
  having
• 0:59
  the
• 1:00
  energy
• 1:00
  to
• 1:00
  go
• 1:00
  to
• 1:00
  the
• 1:00
  gym
• 1:01
  again.
• 1:01
  As
• 1:01
  part
• 1:02
  of
• 1:02
  your
• 1:02
  clinic
• 1:03
  standard
• 1:03
  wellness
• 1:03
  screening
• 1:04
  protocol,
• 1:05
  a
• 1:05
  urine
• 1:05
  drug
• 1:05
  screen
• 1:06
  is
• 1:06
  collected
• 1:06
  and
• 1:07
  her
• 1:07
  results
• 1:07
  return
• 1:08
  with
• 1:08
  a
• 1:08
  positive
• 1:09
  benzodiazepine
• 1:10
  screen
• 1:10
  and
• 1:10
  a
• 1:10
  positive
• 1:11
  amphetamine
• 1:11
  screen.
• 1:12
  But
• 1:12
  all
• 1:12
  other
• 1:12
  panels
• 1:13
  are
• 1:13
  negative.
• 1:14
  She
• 1:15
  has
• 1:15
  no
• 1:16
  history
• 1:16
  of
• 1:16
  substance
• 1:17
  use
• 1:17
  disorder,
• 1:17
  she's
• 1:18
  never
• 1:18
  been
• 1:18
  prescribed
• 1:18
  a
• 1:19
  benzo
• 1:19
  or
• 1:19
  a
• 1:19
  stimulant
• 1:20
  and
• 1:20
  she
• 1:20
  takes
• 1:20
  no
• 1:21
  over
• 1:21
  the
• 1:21
  counter
• 1:22
  medications
• 1:22
  or
• 1:22
  supplements.
• 1:23
  To
• 1:23
  your
• 1:23
  knowledge,
• 1:24
  she
• 1:24
  is
• 1:24
  visibly
• 1:25
  upset
• 1:26
  by
• 1:26
  these
• 1:26
  results.
• 1:27
  Now,
• 1:27
  which
• 1:27
  of
• 1:27
  the
• 1:27
  following
• 1:28
  is
• 1:28
  the
• 1:28
  next
• 1:29
  appropriate
• 1:30
  step
• 1:31
  for
• 1:31
  you
• 1:31
  or
• 1:32
  the
• 1:32
  most
• 1:32
  appropriate
• 1:33
  step
• 1:33
  for
• 1:33
  you
• 1:33
  as
• 1:33
  the
• 1:34
  clinician?
• 1:34
  So
• 1:35
  what's
• 1:35
  the
• 1:35
  next
• 1:35
  most
• 1:36
  appropriate
• 1:37
  step?
• 1:37
  Is
• 1:37
  it
• 1:38
  a
• 1:38
  discontinue
• 1:39
  bupropion
• 1:40
  due
• 1:40
  to
• 1:41
  concern
• 1:41
  for
• 1:42
  stimulant
• 1:42
  misuse
• 1:43
  that
• 1:43
  may
• 1:43
  be
• 1:43
  potentiating
• 1:44
  its
• 1:44
  seizure
• 1:45
  risk?
• 1:45
  And
• 1:46
  then
• 1:46
  you
• 1:46
  should
• 1:46
  switch
• 1:46
  to
• 1:47
  an
• 1:47
  ssri.
• 1:48
  Is
• 1:48
  it
• 1:48
  B?
• 1:50
  Add
• 1:50
  a
• 1:50
  benzodiazepine
• 1:51
  taper
• 1:52
  given
• 1:52
  the
• 1:53
  positive
• 1:53
  screen
• 1:54
  suggests
• 1:55
  undisclosed
• 1:56
  chronic
• 1:56
  benzodiazepine
• 1:57
  use
• 1:58
  and
• 1:58
  risk
• 1:58
  of
• 1:58
  withdrawal.
• 2:00
  Or
• 2:00
  C,
• 2:01
  refer
• 2:02
  the
• 2:02
  patient
• 2:02
  for
• 2:03
  formal
• 2:03
  substance
• 2:04
  use
• 2:04
  disorder
• 2:04
  evaluation
• 2:05
  and
• 2:06
  defer
• 2:06
  refills
• 2:07
  of
• 2:07
  her
• 2:07
  current
• 2:07
  medications
• 2:08
  until
• 2:08
  that
• 2:08
  evaluation
• 2:09
  is
• 2:09
  complete.
• 2:10
  Or
• 2:10
  is
• 2:10
  it
• 2:11
  D?
• 2:12
  Reassure
• 2:12
  the
• 2:12
  patient
• 2:13
  that
• 2:13
  her
• 2:13
  current
• 2:14
  medications
• 2:14
  are
• 2:14
  most
• 2:15
  are
• 2:16
  the
• 2:16
  most
• 2:16
  likely
• 2:16
  explanation
• 2:17
  it
• 2:19
  and
• 2:19
  order
• 2:20
  confirmatory
• 2:20
  testing
• 2:22
  before
• 2:22
  any
• 2:23
  changes.
• 2:24
  Or
• 2:24
  is
• 2:25
  it
• 2:25
  E?
• 2:27
  Repeat
• 2:27
  the
• 2:27
  immunoassay
• 2:28
  in
• 2:28
  two
• 2:29
  weeks
• 2:30
  to
• 2:30
  see
• 2:30
  if
• 2:30
  results
• 2:31
  are
• 2:31
  consistent
• 2:32
  before
• 2:32
  you
• 2:32
  take
• 2:33
  any
• 2:33
  further
• 2:34
  action.
• 2:37
  We
• 2:37
  could
• 2:37
  go
• 2:37
  to
• 2:38
  the
• 2:38
  Greek
• 2:38
  Alphabet.
• 2:39
  We
• 2:39
  could
• 2:39
  go
• 2:39
  to
• 2:39
  the
• 2:40
  ancient
• 2:40
  Phoenician.
• 2:42
  You
• 2:42
  get
• 2:42
  my
• 2:42
  point,
• 2:42
  right?
• 2:43
  Psychiatry
• 2:44
  is
• 2:44
  really
• 2:44
  layered.
• 2:45
  Okay,
• 2:46
  but
• 2:46
  think
• 2:46
  about
• 2:47
  It.
• 2:47
  Press
• 2:47
  pause
• 2:47
  if
• 2:48
  you
• 2:48
  need
• 2:48
  to,
• 2:48
  and
• 2:48
  I'm
• 2:48
  about
• 2:49
  to
• 2:49
  give
• 2:49
  you
• 2:50
  the
• 2:50
  wrong
• 2:50
  answers.
• 2:51
  You
• 2:51
  know,
• 2:51
  I.
• 2:51
  You
• 2:51
  know,
• 2:52
  I
• 2:52
  love
• 2:52
  to
• 2:52
  give
• 2:52
  you
• 2:52
  the
• 2:52
  wrong
• 2:52
  answers
• 2:53
  first.
• 2:53
  Kind
• 2:54
  of
• 2:54
  gets
• 2:54
  us
• 2:54
  to
• 2:54
  the
• 2:54
  right
• 2:55
  answer.
• 2:56
  So
• 2:56
  what
• 2:56
  do
• 2:56
  we
• 2:56
  have
• 2:56
  here,
• 2:57
  my
• 2:57
  friends?
• 2:57
  We
• 2:58
  have
• 2:58
  a
• 2:58
  bit
• 2:58
  of
• 2:58
  an
• 2:58
  unusual
• 2:59
  situation,
• 3:00
  actually.
• 3:00
  Somebody
• 3:01
  who's
• 3:01
  seemingly
• 3:02
  doing
• 3:02
  well.
• 3:03
  Right?
• 3:04
  I
• 3:04
  mean,
• 3:04
  this
• 3:04
  is
• 3:04
  somebody.
• 3:05
  She's
• 3:05
  on
• 3:05
  two
• 3:05
  kind
• 3:06
  of
• 3:06
  peanut
• 3:06
  butter
• 3:06
  and
• 3:06
  jelly
• 3:07
  medications,
• 3:07
  Trazodone
• 3:08
  and
• 3:08
  Wellbutrin.
• 3:09
  They're
• 3:09
  decent
• 3:09
  doses.
• 3:10
  And
• 3:10
  she's
• 3:11
  telling
• 3:11
  you
• 3:11
  subjectively
• 3:12
  that
• 3:12
  she's
• 3:12
  doing
• 3:13
  really
• 3:13
  well.
• 3:14
  She's
• 3:14
  stable.
• 3:14
  You've
• 3:15
  seen
• 3:15
  her
• 3:15
  for
• 3:15
  multiple
• 3:16
  months.
• 3:16
  Everything
• 3:17
  looks
• 3:17
  really
• 3:17
  good.
• 3:18
  She's
• 3:18
  denying
• 3:19
  any
• 3:19
  substance
• 3:19
  use,
• 3:20
  so
• 3:20
  it's
• 3:20
  a
• 3:21
  little
• 3:21
  strange
• 3:21
  that
• 3:21
  she's
• 3:21
  popping
• 3:22
  positive
• 3:22
  here.
• 3:23
  And
• 3:24
  I
• 3:24
  think
• 3:24
  the
• 3:24
  other
• 3:24
  key
• 3:25
  is
• 3:25
  that,
• 3:25
  you
• 3:26
  know,
• 3:26
  her
• 3:26
  exam
• 3:26
  is
• 3:27
  unremarkable.
• 3:27
  She's.
• 3:28
  Her
• 3:28
  mood
• 3:28
  is
• 3:29
  good.
• 3:29
  So
• 3:30
  there's
• 3:30
  no
• 3:30
  evidence
• 3:30
  in
• 3:30
  your
• 3:31
  office,
• 3:31
  at
• 3:31
  least,
• 3:32
  that
• 3:33
  she's
• 3:34
  abusing
• 3:34
  any
• 3:34
  substances.
• 3:35
  Now,
• 3:35
  it's
• 3:35
  not
• 3:36
  clear
• 3:36
  that
• 3:37
  you
• 3:37
  would
• 3:37
  necessarily
• 3:38
  know
• 3:38
  right
• 3:39
  away
• 3:39
  if
• 3:39
  your
• 3:39
  patient
• 3:40
  is
• 3:40
  abusing
• 3:40
  substances
• 3:41
  in
• 3:41
  your
• 3:41
  office.
• 3:41
  Definitely.
• 3:42
  Patients
• 3:42
  will
• 3:42
  come.
• 3:43
  And
• 3:43
  sometimes
• 3:44
  you
• 3:44
  can
• 3:44
  smell
• 3:44
  alcohol.
• 3:45
  Sure,
• 3:46
  Sometimes
• 3:46
  you
• 3:46
  can
• 3:46
  tell
• 3:47
  if
• 3:47
  your
• 3:47
  patient
• 3:48
  is
• 3:48
  on
• 3:49
  an
• 3:49
  amphetamine
• 3:50
  or
• 3:50
  methamphetamine.
• 3:51
  But
• 3:51
  that's
• 3:51
  not
• 3:51
  what
• 3:51
  we're
• 3:51
  seeing
• 3:52
  here
• 3:52
  with
• 3:52
  Bonnie.
• 3:53
  We're
• 3:53
  seeing
• 3:53
  a
• 3:53
  pretty
• 3:53
  standard
• 3:54
  cookie
• 3:54
  cutter
• 3:55
  outpatient,
• 3:56
  outpatient
• 3:57
  encounter.
• 3:58
  So,
• 3:58
  you
• 3:59
  know,
• 3:59
  again,
• 3:59
  leaning
• 3:59
  on
• 4:00
  your.
• 4:00
  This
• 4:00
  is
• 4:00
  why
• 4:00
  you
• 4:00
  really
• 4:00
  have
• 4:01
  to
• 4:01
  lean
• 4:01
  on
• 4:01
  your
• 4:01
  mental
• 4:01
  status
• 4:02
  exam.
• 4:02
  I
• 4:02
  know
• 4:02
  we're
• 4:03
  kind
• 4:03
  of
• 4:03
  talking
• 4:03
  here
• 4:03
  over
• 4:04
  a
• 4:04
  podcast
• 4:04
  episode,
• 4:05
  but
• 4:06
  the
• 4:06
  mental
• 4:06
  status
• 4:07
  exam
• 4:07
  is
• 4:07
  nothing
• 4:08
  to
• 4:08
  sneeze
• 4:08
  at,
• 4:08
  right?
• 4:09
  Because
• 4:09
  there's
• 4:09
  a
• 4:09
  lot
• 4:09
  of
• 4:09
  little
• 4:10
  clues
• 4:10
  in
• 4:10
  that
• 4:10
  exam
• 4:11
  that
• 4:11
  something
• 4:11
  is
• 4:12
  wrong.
• 4:12
  You
• 4:12
  know,
• 4:12
  we
• 4:12
  already
• 4:13
  just
• 4:13
  talked
• 4:13
  about
• 4:13
  psychomotor
• 4:14
  agitation
• 4:14
  or
• 4:14
  psychomotor
• 4:15
  retardation.
• 4:16
  If
• 4:16
  somebody's
• 4:17
  really
• 4:17
  in
• 4:17
  a
• 4:17
  stupor
• 4:18
  or
• 4:18
  lethargic,
• 4:19
  you
• 4:19
  might
• 4:19
  worry
• 4:19
  that
• 4:19
  they're
• 4:20
  on
• 4:20
  too
• 4:20
  many
• 4:20
  benzodiazepines
• 4:21
  or
• 4:21
  maybe
• 4:21
  that
• 4:22
  they're
• 4:22
  withdrawing
• 4:22
  from
• 4:22
  benzodiazepines
• 4:23
  and
• 4:23
  they're
• 4:24
  really
• 4:24
  anxious
• 4:24
  and
• 4:24
  they
• 4:24
  want
• 4:25
  to
• 4:25
  crawl
• 4:25
  out
• 4:25
  of
• 4:25
  their
• 4:25
  skin
• 4:26
  and
• 4:26
  they're
• 4:26
  pacing
• 4:26
  and
• 4:27
  panicking.
• 4:27
  Right?
• 4:28
  So
• 4:28
  those
• 4:28
  would
• 4:28
  be
• 4:28
  little
• 4:29
  cues
• 4:29
  that
• 4:30
  something's
• 4:30
  not
• 4:30
  right.
• 4:30
  They
• 4:31
  would
• 4:31
  be
• 4:31
  dysphoric,
• 4:31
  maybe
• 4:32
  if
• 4:32
  they
• 4:32
  were
• 4:33
  on
• 4:33
  methamphetamines.
• 4:34
  That'd
• 4:34
  be
• 4:34
  really
• 4:34
  grandiose.
• 4:35
  They'd
• 4:35
  be
• 4:35
  talking
• 4:35
  really
• 4:36
  fast
• 4:36
  without
• 4:36
  any
• 4:37
  interruptions.
• 4:37
  They
• 4:38
  might
• 4:38
  exhibit
• 4:38
  more
• 4:38
  manic,
• 4:39
  like,
• 4:39
  behavior.
• 4:40
  So
• 4:40
  I'm
• 4:40
  not
• 4:40
  saying
• 4:41
  that
• 4:41
  every
• 4:41
  single
• 4:42
  substance
• 4:43
  abuse
• 4:43
  encounter
• 4:43
  is
• 4:44
  going
• 4:44
  to
• 4:44
  be
• 4:44
  blatantly
• 4:44
  obvious
• 4:45
  to
• 4:45
  you,
• 4:45
  but
• 4:46
  the
• 4:46
  mental
• 4:46
  status
• 4:46
  exam
• 4:47
  can
• 4:47
  kind
• 4:47
  of
• 4:47
  clue
• 4:48
  you
• 4:48
  in
• 4:48
  on
• 4:49
  whether
• 4:49
  or
• 4:49
  not.
• 4:49
  You
• 4:50
  should
• 4:50
  be
• 4:50
  concerned
• 4:50
  to
• 4:51
  an
• 4:51
  extent.
• 4:51
  And
• 4:52
  then
• 4:52
  of
• 4:52
  course,
• 4:52
  there's
• 4:52
  that
• 4:53
  weird
• 4:53
  gray
• 4:54
  area
• 4:54
  where
• 4:54
  maybe
• 4:54
  your
• 4:54
  patient
• 4:55
  is
• 4:55
  absolutely
• 4:56
  abusing
• 4:56
  substances
• 4:57
  and
• 4:57
  you
• 4:57
  can't
• 4:57
  really
• 4:57
  pick
• 4:58
  it
• 4:58
  up
• 4:58
  on
• 4:58
  an
• 4:58
  MSC
• 4:58
  that
• 4:59
  easily.
• 5:00
  They
• 5:00
  could
• 5:00
  be
• 5:00
  malingering.
• 5:00
  They
• 5:01
  could
• 5:01
  be
• 5:01
  just
• 5:02
  not
• 5:02
  telling
• 5:02
  you
• 5:03
  what
• 5:03
  date
• 5:03
  you
• 5:03
  need
• 5:03
  to
• 5:03
  know
• 5:04
  for
• 5:04
  your
• 5:04
  assessment.
• 5:05
  But
• 5:06
  either
• 5:06
  way,
• 5:06
  we
• 5:07
  have
• 5:07
  something
• 5:07
  strange
• 5:07
  here
• 5:08
  where
• 5:08
  everything's
• 5:08
  going
• 5:08
  well.
• 5:09
  Now,
• 5:09
  the
• 5:09
  one
• 5:09
  thing
• 5:10
  that's
• 5:10
  a
• 5:10
  little
• 5:10
  bizarre,
• 5:11
  you
• 5:11
  could
• 5:11
  argue,
• 5:12
  is
• 5:12
  that
• 5:12
  she
• 5:13
  said
• 5:13
  she
• 5:13
  finally
• 5:14
  has
• 5:14
  the
• 5:14
  energy
• 5:14
  to
• 5:14
  go
• 5:14
  to
• 5:15
  the
• 5:15
  gym
• 5:15
  again.
• 5:16
  Now,
• 5:16
  that
• 5:16
  is
• 5:17
  either
• 5:18
  a
• 5:18
  red
• 5:19
  flag
• 5:19
  or
• 5:20
  a
• 5:20
  red
• 5:20
  herring.
• 5:21
  Right?
• 5:22
  So
• 5:22
  that
• 5:22
  kind
• 5:23
  of
• 5:23
  thing
• 5:23
  is
• 5:24
  why
• 5:24
  we
• 5:24
  get
• 5:24
  paid
• 5:25
  the
• 5:25
  big
• 5:25
  bucks
• 5:25
  to
• 5:25
  sit
• 5:25
  in
• 5:26
  front
• 5:26
  of
• 5:26
  our
• 5:26
  patients
• 5:26
  and
• 5:27
  parse
• 5:27
  this
• 5:28
  out.
• 5:28
  Right?
• 5:28
  Because
• 5:29
  that
• 5:29
  could
• 5:29
  be
• 5:30
  construed
• 5:31
  as
• 5:31
  mania
• 5:32
  or
• 5:32
  hypomania.
• 5:33
  Somebody
• 5:33
  who's
• 5:34
  so
• 5:34
  frantic
• 5:35
  and
• 5:35
  engaged
• 5:35
  in
• 5:36
  so
• 5:36
  many
• 5:36
  projects
• 5:37
  and
• 5:37
  maybe
• 5:37
  exercising
• 5:38
  to
• 5:38
  the
• 5:39
  point
• 5:39
  of
• 5:39
  exhaustion
• 5:39
  where
• 5:40
  they're
• 5:40
  losing
• 5:40
  a
• 5:40
  lot
• 5:40
  of
• 5:40
  weight
• 5:41
  rapidly,
• 5:42
  that
• 5:42
  could
• 5:42
  mean
• 5:43
  that
• 5:43
  she's
• 5:44
  on
• 5:44
  stimulants
• 5:45
  and
• 5:45
  she
• 5:45
  has
• 5:45
  no
• 5:46
  appetite,
• 5:46
  and
• 5:46
  that's
• 5:46
  why
• 5:47
  she's
• 5:47
  losing
• 5:47
  £12.
• 5:48
  And
• 5:48
  hence
• 5:48
  we
• 5:48
  do
• 5:48
  have
• 5:48
  a
• 5:49
  positive
• 5:49
  amphetamine
• 5:50
  result.
• 5:51
  So
• 5:51
  that's
• 5:51
  definitely,
• 5:52
  again,
• 5:52
  either
• 5:53
  a
• 5:53
  red
• 5:54
  flag
• 5:54
  or
• 5:54
  a
• 5:54
  red
• 5:54
  herring,
• 5:55
  because
• 5:55
  it
• 5:55
  could
• 5:55
  be
• 5:56
  rather
• 5:56
  innocent
• 5:56
  in
• 5:57
  that
• 5:57
  it's
• 5:57
  a
• 5:58
  side
• 5:58
  effect
• 5:58
  of
• 5:58
  the
• 5:59
  Wellbutrin.
• 5:59
  There
• 5:59
  are
• 6:00
  people
• 6:00
  who
• 6:00
  lose
• 6:00
  weight
• 6:00
  on
• 6:00
  Wellbutrin.
• 6:01
  There
• 6:01
  are
• 6:01
  people
• 6:01
  who
• 6:02
  routinely
• 6:02
  report
• 6:02
  having
• 6:03
  more
• 6:03
  energy,
• 6:03
  like.
• 6:04
  No,
• 6:04
  she
• 6:04
  didn't
• 6:04
  say
• 6:05
  that.
• 6:05
  Right.
• 6:05
  That
• 6:05
  would
• 6:05
  be
• 6:06
  the
• 6:06
  red
• 6:06
  flag,
• 6:07
  this
• 6:07
  kind
• 6:07
  of
• 6:07
  frenzied,
• 6:08
  impulsive
• 6:09
  behavior
• 6:10
  as
• 6:10
  a
• 6:10
  result
• 6:10
  of
• 6:11
  maybe
• 6:11
  an
• 6:11
  amphetamine
• 6:12
  that
• 6:12
  induces
• 6:12
  mania.
• 6:13
  Right.
• 6:13
  You
• 6:13
  see
• 6:13
  kind
• 6:13
  of
• 6:14
  a
• 6:14
  broad
• 6:14
  constellation
• 6:15
  of
• 6:15
  concerning
• 6:16
  symptoms.
• 6:17
  Not
• 6:17
  this
• 6:18
  relatively
• 6:19
  benign.
• 6:19
  It's
• 6:20
  not
• 6:20
  even
• 6:20
  benign.
• 6:21
  It's
• 6:21
  actually
• 6:21
  a
• 6:21
  very
• 6:21
  healthy
• 6:22
  thing.
• 6:22
  Right.
• 6:22
  She
• 6:22
  has
• 6:23
  the
• 6:23
  energy
• 6:23
  to
• 6:23
  go
• 6:23
  to
• 6:23
  the
• 6:24
  gym.
• 6:24
  And
• 6:24
  sometimes
• 6:25
  if
• 6:25
  you
• 6:25
  get
• 6:25
  worried
• 6:26
  that
• 6:26
  this
• 6:26
  is
• 6:26
  still
• 6:26
  some
• 6:27
  part
• 6:27
  of
• 6:27
  an
• 6:27
  impulsive
• 6:28
  hypomanic
• 6:29
  behavior
• 6:30
  that
• 6:30
  again,
• 6:30
  may
• 6:30
  be
• 6:31
  induced
• 6:31
  by
• 6:31
  her
• 6:31
  positive
• 6:32
  amphetamine
• 6:33
  result,
• 6:34
  then
• 6:34
  I
• 6:34
  would
• 6:35
  ask
• 6:35
  questions
• 6:35
  about
• 6:35
  the
• 6:36
  gym.
• 6:36
  I
• 6:36
  would
• 6:36
  want
• 6:36
  to
• 6:37
  know,
• 6:37
  like,
• 6:37
  well,
• 6:37
  walk
• 6:37
  me
• 6:38
  through
• 6:38
  kind
• 6:38
  of
• 6:38
  what
• 6:38
  made
• 6:39
  you
• 6:39
  get
• 6:39
  the
• 6:39
  gym
• 6:39
  membership
• 6:39
  and
• 6:40
  what
• 6:40
  do
• 6:40
  you
• 6:40
  do
• 6:40
  when
• 6:40
  you
• 6:40
  go
• 6:40
  to
• 6:41
  the
• 6:41
  gym?
• 6:41
  How
• 6:41
  often
• 6:41
  do
• 6:42
  you
• 6:42
  go
• 6:42
  to
• 6:42
  the
• 6:42
  gym?
• 6:42
  Right?
• 6:43
  And
• 6:43
  if
• 6:43
  the
• 6:43
  answer
• 6:44
  is
• 6:44
  really
• 6:44
  frenzied
• 6:45
  and
• 6:45
  impulsive,
• 6:45
  Oh,
• 6:46
  I
• 6:46
  joined
• 6:46
  a
• 6:46
  24
• 6:47
  hour
• 6:47
  Planet
• 6:47
  Fitness
• 6:48
  and
• 6:48
  I
• 6:48
  go
• 6:48
  there
• 6:48
  from
• 6:48
  10pm
• 6:49
  to
• 6:49
  6am
• 6:50
  and
• 6:50
  I
• 6:51
  just
• 6:51
  love
• 6:51
  it
• 6:51
  there.
• 6:51
  I
• 6:51
  talk
• 6:52
  to
• 6:52
  everybody
• 6:52
  there.
• 6:52
  I'm
• 6:52
  pitching
• 6:53
  my
• 6:53
  own
• 6:53
  personal
• 6:54
  training
• 6:55
  business
• 6:55
  to
• 6:55
  the
• 6:56
  managers.
• 6:56
  And
• 6:57
  yeah,
• 6:57
  they
• 6:57
  kicked
• 6:57
  me
• 6:58
  out,
• 6:58
  but
• 6:58
  I
• 6:58
  go
• 6:58
  back
• 6:59
  all
• 6:59
  the
• 6:59
  time.
• 6:59
  Right.
• 6:59
  If
• 6:59
  you
• 7:00
  get
• 7:00
  this
• 7:00
  weird
• 7:00
  frenzied
• 7:01
  cluster
• 7:01
  of
• 7:02
  symptoms
• 7:02
  where
• 7:02
  they're
• 7:03
  high
• 7:03
  energy,
• 7:03
  they're
• 7:03
  not
• 7:03
  sleeping,
• 7:04
  they're
• 7:04
  really
• 7:04
  ambitious,
• 7:05
  they're
• 7:05
  goal
• 7:05
  directed,
• 7:06
  they're
• 7:06
  disorganized.
• 7:07
  Then,
• 7:07
  yeah,
• 7:07
  I'm
• 7:08
  kind
• 7:08
  of
• 7:08
  scared.
• 7:08
  At
• 7:08
  that
• 7:08
  point,
• 7:09
  I'm
• 7:09
  paying
• 7:09
  more
• 7:09
  attention
• 7:10
  to
• 7:10
  the
• 7:10
  positive
• 7:11
  amphetamine
• 7:12
  result.
• 7:12
  But
• 7:12
  if
• 7:12
  your
• 7:13
  patient
• 7:13
  tells
• 7:13
  you,
• 7:13
  oh,
• 7:13
  no,
• 7:14
  I
• 7:14
  go
• 7:14
  to
• 7:14
  the
• 7:14
  gym,
• 7:14
  you
• 7:15
  know,
• 7:15
  three
• 7:15
  times
• 7:15
  a
• 7:15
  week,
• 7:16
  I
• 7:16
  do
• 7:16
  leg
• 7:17
  day
• 7:17
  on
• 7:17
  Monday,
• 7:17
  chest
• 7:18
  day
• 7:18
  on
• 7:18
  Wednesday,
• 7:19
  and
• 7:19
  back
• 7:20
  day
• 7:20
  on
• 7:20
  Friday,
• 7:20
  and
• 7:21
  then
• 7:21
  I
• 7:21
  do
• 7:21
  long
• 7:21
  form
• 7:22
  cardio
• 7:22
  on
• 7:22
  Sundays,
• 7:23
  that
• 7:24
  sounds
• 7:24
  pretty
• 7:24
  methodical,
• 7:25
  thought
• 7:25
  out,
• 7:26
  structured.
• 7:27
  It
• 7:27
  doesn't
• 7:27
  sound
• 7:28
  impulsive,
• 7:28
  it
• 7:28
  sounds
• 7:28
  very
• 7:29
  reasonable.
• 7:29
  And
• 7:30
  it
• 7:30
  sounds
• 7:30
  reasonable
• 7:31
  that
• 7:31
  you
• 7:31
  could
• 7:31
  lose
• 7:31
  12
• 7:32
  pounds
• 7:32
  in,
• 7:33
  in
• 7:34
  a
• 7:34
  very
• 7:34
  short
• 7:34
  period
• 7:35
  of
• 7:35
  time.
• 7:35
  So
• 7:36
  none
• 7:36
  of
• 7:36
  that
• 7:36
  is
• 7:37
  concerning.
• 8:32
  That
• 8:32
  would
• 8:32
  reduce
• 8:33
  my
• 8:33
  index
• 8:33
  of
• 8:33
  suspicion
• 8:34
  that
• 8:34
  this
• 8:34
  amphetamine
• 8:35
  result
• 8:35
  is
• 8:35
  either
• 8:36
  truly
• 8:36
  positive
• 8:37
  or
• 8:37
  if,
• 8:38
  you
• 8:38
  know,
• 8:39
  whatever
• 8:39
  else
• 8:39
  might
• 8:40
  be
• 8:40
  happening.
• 8:40
  And
• 8:40
  we'll
• 8:40
  talk
• 8:41
  about
• 8:41
  that.
• 8:42
  But
• 8:42
  anyhow,
• 8:42
  it's,
• 8:43
  it's
• 8:43
  a
• 8:43
  pretty
• 8:43
  interesting
• 8:44
  case
• 8:44
  so
• 8:44
  far.
• 8:44
  So
• 8:45
  this
• 8:45
  is
• 8:45
  also
• 8:45
  where
• 8:45
  not
• 8:45
  only
• 8:46
  the
• 8:46
  mental
• 8:46
  status
• 8:46
  exam
• 8:47
  is
• 8:47
  important,
• 8:47
  but
• 8:48
  it's
• 8:48
  also
• 8:48
  very
• 8:48
  important
• 8:49
  that
• 8:49
  you
• 8:50
  press
• 8:50
  them
• 8:51
  on
• 8:51
  either
• 8:51
  the
• 8:51
  red
• 8:51
  flags
• 8:52
  or
• 8:52
  the
• 8:52
  red
• 8:52
  herrings.
• 8:53
  Right.
• 8:53
  And
• 8:53
  the
• 8:53
  weird
• 8:54
  part
• 8:54
  here
• 8:54
  is
• 8:55
  the
• 8:55
  losing
• 8:56
  a
• 8:56
  lot
• 8:56
  of
• 8:56
  weight.
• 8:56
  I
• 8:56
  would
• 8:56
  also
• 8:57
  want
• 8:57
  to
• 8:57
  make
• 8:57
  sure
• 8:57
  that
• 8:57
  this
• 8:58
  isn't
• 8:58
  like
• 8:58
  intentional
• 8:59
  restricted
• 8:59
  eating.
• 9:00
  Maybe
• 9:00
  the
• 9:00
  amphetamine
• 9:01
  use,
• 9:01
  again,
• 9:01
  is
• 9:02
  a
• 9:02
  result
• 9:02
  of
• 9:02
  an
• 9:02
  anorexic
• 9:03
  symptom
• 9:04
  cluster
• 9:04
  where
• 9:04
  the
• 9:05
  patient
• 9:05
  has
• 9:05
  a
• 9:05
  disturbed
• 9:06
  body
• 9:06
  image
• 9:07
  and
• 9:07
  they're
• 9:07
  trying
• 9:07
  to
• 9:08
  lose
• 9:08
  weight
• 9:08
  by
• 9:09
  restricting
• 9:09
  calories
• 9:09
  or
• 9:10
  taking
• 9:10
  medications
• 9:11
  that
• 9:11
  deliberately
• 9:12
  suppress
• 9:12
  appetite.
• 9:13
  So
• 9:13
  it's
• 9:13
  fair
• 9:14
  game
• 9:14
  to
• 9:14
  ask
• 9:14
  those
• 9:15
  questions
• 9:15
  in
• 9:15
  a
• 9:15
  nonjudgmental
• 9:16
  way.
• 9:16
  You
• 9:16
  can
• 9:16
  naturally
• 9:17
  ask
• 9:17
  that
• 9:17
  question.
• 9:18
  Oh,
• 9:18
  well,
• 9:18
  it's
• 9:18
  great
• 9:18
  you've
• 9:18
  lost
• 9:19
  weight.
• 9:19
  I'm
• 9:19
  really
• 9:19
  happy
• 9:20
  to
• 9:20
  hear
• 9:20
  you've
• 9:20
  lost
• 9:21
  £12.
• 9:21
  Were
• 9:21
  you
• 9:22
  intending
• 9:22
  to
• 9:22
  do
• 9:22
  that?
• 9:23
  Oh,
• 9:23
  yeah,
• 9:23
  I,
• 9:23
  you
• 9:24
  know,
• 9:24
  my
• 9:24
  cardiologist
• 9:25
  said
• 9:25
  it
• 9:25
  would
• 9:25
  be
• 9:25
  good
• 9:25
  If
• 9:26
  I
• 9:26
  lost
• 9:26
  10
• 9:26
  to
• 9:26
  50.
• 9:27
  £20.
• 9:27
  10
• 9:28
  to
• 9:28
  50.
• 9:28
  I
• 9:28
  would
• 9:28
  be
• 9:28
  upset
• 9:29
  if
• 9:29
  my
• 9:29
  cardiologist
• 9:30
  told
• 9:30
  me
• 9:30
  I
• 9:30
  need
• 9:30
  to
• 9:30
  lose
• 9:30
  £50
• 9:32
  if,
• 9:32
  you
• 9:32
  know,
• 9:32
  but
• 9:33
  if
• 9:33
  she
• 9:33
  says,
• 9:33
  oh,
• 9:33
  yeah,
• 9:33
  my
• 9:34
  cardiologist
• 9:34
  or
• 9:34
  my
• 9:34
  PCP
• 9:35
  says
• 9:35
  that
• 9:35
  I
• 9:36
  should
• 9:36
  lose
• 9:36
  between
• 9:36
  10
• 9:37
  and
• 9:37
  20
• 9:37
  pounds
• 9:37
  this
• 9:38
  year.
• 9:38
  And
• 9:39
  honestly,
• 9:39
  the
• 9:39
  first
• 9:39
  10
• 9:40
  came
• 9:40
  out
• 9:40
  pretty
• 9:40
  easy.
• 9:41
  But
• 9:41
  you
• 9:41
  can
• 9:41
  kind
• 9:41
  of
• 9:42
  gently
• 9:42
  probe
• 9:42
  that
• 9:43
  and
• 9:44
  assess
• 9:44
  whether
• 9:44
  this
• 9:45
  is
• 9:45
  desired
• 9:45
  weight
• 9:46
  loss.
• 9:46
  Is
• 9:46
  it
• 9:46
  desired
• 9:47
  for
• 9:47
  her
• 9:47
  health
• 9:47
  and
• 9:48
  wellness
• 9:48
  or
• 9:48
  is
• 9:49
  it
• 9:49
  desired
• 9:49
  because
• 9:50
  the
• 9:50
  root
• 9:50
  cause
• 9:50
  is
• 9:51
  a
• 9:51
  disturbed
• 9:51
  body
• 9:51
  image?
• 9:52
  Right.
• 9:53
  And
• 9:53
  I
• 9:53
  would
• 9:54
  not
• 9:54
  like
• 9:54
  interrogate
• 9:55
  her
• 9:55
  either,
• 9:56
  like
• 9:56
  Sherlock
• 9:57
  Holmes
• 9:57
  style,
• 9:58
  just
• 9:58
  because
• 9:58
  she
• 9:58
  lost
• 9:58
  weight?
• 9:59
  Right.
• 9:59
  You
• 9:59
  don't
• 9:59
  want
• 9:59
  to
• 9:59
  make
• 10:00
  this
• 10:00
  sound
• 10:00
  like
• 10:00
  a
• 10:01
  judgmental
• 10:01
  interrogation,
• 10:03
  okay?
• 10:03
  Don't
• 10:04
  stand
• 10:04
  and
• 10:04
  hover
• 10:05
  over
• 10:05
  your
• 10:05
  patient
• 10:06
  or
• 10:06
  circle
• 10:06
  them
• 10:07
  around
• 10:07
  like.
• 10:08
  Walk
• 10:08
  around
• 10:09
  them
• 10:09
  in
• 10:09
  circles
• 10:10
  like
• 10:10
  a
• 10:10
  shark.
• 10:10
  This
• 10:10
  is
• 10:11
  not
• 10:11
  the
• 10:11
  kind
• 10:12
  of
• 10:12
  job
• 10:12
  for
• 10:12
  that.
• 10:12
  If
• 10:12
  that's
• 10:13
  the
• 10:13
  kind
• 10:13
  of
• 10:13
  thing
• 10:13
  that
• 10:13
  you
• 10:14
  like
• 10:14
  to
• 10:14
  do,
• 10:14
  you
• 10:15
  should
• 10:15
  definitely
• 10:15
  go
• 10:15
  pursue
• 10:16
  a
• 10:16
  criminal
• 10:17
  justice
• 10:17
  degree,
• 10:18
  become
• 10:18
  a
• 10:18
  detective.
• 10:19
  There
• 10:19
  are
• 10:19
  plenty
• 10:20
  of
• 10:20
  jobs
• 10:20
  where
• 10:20
  you
• 10:21
  can
• 10:21
  walk
• 10:21
  around
• 10:22
  somebody
• 10:23
  in
• 10:23
  a
• 10:23
  chair
• 10:23
  and
• 10:23
  intimidate
• 10:24
  them.
• 10:25
  That's
• 10:25
  not
• 10:25
  psychiatry.
• 10:26
  That's
• 10:26
  not
• 10:26
  what
• 10:26
  we
• 10:26
  do.
• 10:26
  We
• 10:26
  want
• 10:27
  to
• 10:27
  destigmatize
• 10:28
  these
• 10:28
  issues
• 10:29
  as
• 10:29
  much
• 10:29
  as
• 10:29
  possible.
• 10:30
  Okay?
• 10:30
  So
• 10:31
  you
• 10:31
  have
• 10:31
  this
• 10:31
  benzodiazepine
• 10:32
  thing
• 10:32
  that's
• 10:32
  positive,
• 10:33
  too,
• 10:34
  which
• 10:34
  is
• 10:34
  also
• 10:34
  bizarre.
• 10:35
  And
• 10:35
  by
• 10:36
  the
• 10:36
  way,
• 10:36
  nobody
• 10:37
  said
• 10:37
  you
• 10:37
  couldn't
• 10:37
  just
• 10:37
  ask
• 10:38
  Bonnie,
• 10:38
  hey,
• 10:39
  are
• 10:39
  you
• 10:39
  using
• 10:39
  benzodiazepines
• 10:41
  or
• 10:41
  amphetamines
• 10:42
  on
• 10:42
  the
• 10:42
  side
• 10:43
  to
• 10:43
  kind
• 10:43
  of
• 10:43
  help
• 10:44
  with
• 10:44
  some
• 10:44
  of
• 10:44
  the
• 10:44
  symptoms
• 10:45
  you
• 10:45
  might
• 10:45
  still
• 10:45
  be
• 10:45
  experiencing?
• 10:46
  Because
• 10:46
  that
• 10:47
  can
• 10:47
  be
• 10:47
  quite
• 10:47
  common
• 10:47
  out
• 10:48
  there.
• 10:48
  You
• 10:48
  know,
• 10:48
  normalize
• 10:49
  it.
• 10:50
  Ask
• 10:50
  her
• 10:50
  gently,
• 10:51
  compassionately.
• 10:52
  It's
• 10:52
  all
• 10:52
  about
• 10:52
  your
• 10:52
  tone,
• 10:53
  right?
• 10:53
  There's
• 10:53
  two
• 10:54
  ways
• 10:54
  to
• 10:54
  ask
• 10:54
  a
• 10:54
  question,
• 10:55
  and
• 10:55
  then
• 10:55
  there's
• 10:55
  a
• 10:56
  way
• 10:56
  to
• 10:56
  modulate
• 10:56
  your
• 10:56
  tone.
• 10:57
  If
• 10:57
  you're
• 10:57
  going
• 10:57
  to
• 10:57
  ask
• 10:58
  a
• 10:58
  hard
• 10:58
  question
• 10:59
  that
• 10:59
  might
• 10:59
  involve
• 11:00
  stigma
• 11:01
  or
• 11:01
  some.
• 11:02
  It
• 11:02
  just
• 11:02
  might
• 11:02
  be
• 11:02
  tough.
• 11:03
  It's
• 11:03
  a
• 11:03
  very
• 11:03
  important
• 11:04
  to
• 11:05
  pause
• 11:05
  and
• 11:05
  regulate
• 11:06
  your
• 11:06
  tone
• 11:07
  right
• 11:07
  away
• 11:07
  before
• 11:07
  you
• 11:08
  utter
• 11:08
  the
• 11:08
  words,
• 11:09
  right?
• 11:09
  So
• 11:09
  if
• 11:10
  you're
• 11:10
  asking
• 11:10
  someone
• 11:11
  if
• 11:11
  they're
• 11:11
  taking
• 11:12
  medications
• 11:13
  outside
• 11:13
  of
• 11:13
  your
• 11:14
  treatment
• 11:14
  plan,
• 11:15
  that's
• 11:15
  a
• 11:16
  kind
• 11:16
  of
• 11:16
  a
• 11:16
  loaded
• 11:16
  question.
• 11:17
  It
• 11:17
  may
• 11:17
  come
• 11:17
  across
• 11:18
  as
• 11:18
  accusatory.
• 11:19
  So
• 11:19
  you
• 11:19
  may
• 11:20
  want
• 11:20
  to
• 11:20
  normalize
• 11:20
  that
• 11:21
  right
• 11:21
  away
• 11:21
  and
• 11:21
  modulate
• 11:22
  your
• 11:22
  tone,
• 11:23
  right?
• 11:23
  There's
• 11:23
  a
• 11:23
  nice
• 11:24
  way
• 11:24
  to
• 11:24
  ask
• 11:24
  whether
• 11:24
  they're
• 11:25
  using
• 11:25
  other
• 11:25
  treatments.
• 11:26
  You
• 11:26
  know,
• 11:26
  I
• 11:27
  could
• 11:27
  say,
• 11:27
  you
• 11:28
  know,
• 11:28
  Bonnie,
• 11:28
  a
• 11:29
  lot
• 11:29
  of
• 11:29
  folks,
• 11:30
  they
• 11:30
  do
• 11:30
  whatever
• 11:30
  they
• 11:31
  can
• 11:31
  to
• 11:31
  feel
• 11:31
  better,
• 11:32
  and
• 11:32
  who
• 11:33
  can
• 11:33
  blame
• 11:33
  them?
• 11:33
  And
• 11:34
  because
• 11:34
  we
• 11:34
  have
• 11:34
  these
• 11:35
  positive
• 11:35
  results,
• 11:36
  I
• 11:36
  know
• 11:36
  they're
• 11:36
  upsetting
• 11:37
  to
• 11:37
  you,
• 11:37
  but
• 11:37
  is
• 11:38
  there
• 11:38
  anything
• 11:38
  that
• 11:38
  you'd
• 11:39
  like
• 11:39
  to
• 11:39
  tell
• 11:39
  me
• 11:40
  that
• 11:40
  maybe
• 11:40
  you've
• 11:41
  been
• 11:41
  doing
• 11:41
  on
• 11:41
  the
• 11:41
  side
• 11:42
  to
• 11:42
  help
• 11:42
  feel
• 11:43
  better?
• 11:43
  And
• 11:43
  if
• 11:44
  so,
• 11:44
  we
• 11:44
  can
• 11:44
  totally
• 11:44
  work
• 11:45
  together
• 11:46
  and
• 11:46
  make
• 11:46
  this
• 11:46
  smoother,
• 11:47
  right?
• 11:47
  I
• 11:48
  totally
• 11:48
  recognize
• 11:49
  that
• 11:49
  these
• 11:49
  urine
• 11:50
  drug
• 11:50
  results
• 11:51
  are
• 11:51
  bothering
• 11:52
  you.
• 11:52
  And
• 11:53
  in
• 11:53
  order
• 11:53
  to
• 11:54
  keep
• 11:54
  you
• 11:54
  safe,
• 11:54
  we're
• 11:55
  just
• 11:55
  gonna
• 11:55
  have
• 11:55
  a
• 11:57
  really
• 11:57
  compassionate
• 11:58
  conversation
• 11:58
  together
• 11:59
  and
• 11:59
  just
• 11:59
  get
• 11:59
  to
• 11:59
  the
• 12:00
  bottom
• 12:00
  of
• 12:00
  this
• 12:01
  and
• 12:01
  chat
• 12:01
  about
• 12:01
  your
• 12:02
  options
• 12:02
  and
• 12:02
  what's
• 12:02
  been
• 12:03
  going
• 12:03
  on.
• 12:04
  So
• 12:04
  suffice
• 12:04
  it
• 12:05
  to
• 12:05
  say,
• 12:05
  my
• 12:05
  friends,
• 12:06
  that
• 12:07
  you
• 12:07
  do
• 12:07
  not
• 12:08
  want
• 12:08
  to
• 12:08
  start
• 12:08
  like,
• 12:09
  a
• 12:09
  benzodiazepine
• 12:10
  taper
• 12:10
  here,
• 12:11
  okay?
• 12:12
  Option
• 12:12
  B
• 12:12
  is
• 12:13
  the
• 12:13
  worst
• 12:13
  answer.
• 12:13
  Okay?
• 12:14
  I'm
• 12:14
  not
• 12:14
  trying
• 12:14
  to
• 12:14
  beat
• 12:15
  you
• 12:15
  up
• 12:15
  if
• 12:15
  you
• 12:15
  chose
• 12:15
  option
• 12:16
  B,
• 12:16
  but
• 12:17
  option
• 12:17
  B,
• 12:18
  it
• 12:18
  is
• 12:18
  not
• 12:18
  the
• 12:18
  right
• 12:18
  Answer.
• 12:19
  We
• 12:19
  don't
• 12:19
  wanna
• 12:19
  start
• 12:19
  a
• 12:20
  benzodiazepine
• 12:20
  taper
• 12:21
  and
• 12:21
  kind
• 12:22
  of
• 12:22
  start
• 12:22
  this
• 12:22
  whole
• 12:23
  benzodiazepine
• 12:24
  iatrogenic
• 12:25
  exposure
• 12:25
  potential
• 12:26
  dependence.
• 12:27
  That's
• 12:27
  not
• 12:27
  the
• 12:28
  right
• 12:28
  thing
• 12:28
  to
• 12:28
  do
• 12:28
  right
• 12:29
  away
• 12:29
  and
• 12:30
  certainly
• 12:30
  probably
• 12:30
  not
• 12:31
  at
• 12:31
  all.
• 12:31
  Okay?
• 12:32
  So
• 12:32
  let's
• 12:32
  not
• 12:32
  go
• 12:33
  down
• 12:33
  that
• 12:33
  route.
• 12:33
  Now,
• 12:34
  would
• 12:34
  you
• 12:34
  refer
• 12:34
  this
• 12:35
  patient
• 12:35
  for
• 12:35
  a
• 12:35
  substance
• 12:36
  use
• 12:36
  disorder
• 12:36
  evaluation
• 12:37
  and
• 12:37
  withhold
• 12:38
  psychiatric
• 12:39
  medication
• 12:39
  refills?
• 12:40
  I
• 12:40
  think
• 12:40
  that's
• 12:41
  also
• 12:41
  a
• 12:41
  very
• 12:41
  bad
• 12:42
  choice.
• 12:43
  Number
• 12:43
  one,
• 12:43
  why
• 12:43
  would
• 12:44
  you
• 12:44
  knock
• 12:44
  somebody
• 12:45
  off
• 12:45
  of
• 12:45
  medications
• 12:46
  that
• 12:46
  are
• 12:46
  clearly
• 12:46
  helping
• 12:47
  them?
• 12:47
  Right.
• 12:47
  She
• 12:47
  has
• 12:48
  been
• 12:48
  very
• 12:48
  clear
• 12:49
  about
• 12:49
  the
• 12:49
  fact
• 12:50
  that,
• 12:50
  that
• 12:50
  these
• 12:50
  medications
• 12:51
  have
• 12:51
  helped
• 12:52
  her.
• 12:52
  She's
• 12:53
  no
• 12:53
  longer
• 12:53
  as
• 12:53
  depressed,
• 12:54
  she's
• 12:54
  sleeping
• 12:55
  well,
• 12:55
  she's
• 12:55
  losing
• 12:55
  weight,
• 12:56
  she's
• 12:56
  exercising.
• 12:56
  She
• 12:57
  has
• 12:57
  the
• 12:57
  energy
• 12:57
  to
• 12:57
  take
• 12:57
  care
• 12:58
  of
• 12:58
  herself.
• 12:58
  Knocking
• 12:59
  her
• 12:59
  off
• 12:59
  her
• 12:59
  psychiatric
• 13:00
  medications
• 13:00
  is
• 13:01
  a
• 13:01
  bad
• 13:01
  idea.
• 13:01
  It's
• 13:01
  almost
• 13:02
  always
• 13:03
  a
• 13:03
  bad
• 13:03
  idea
• 13:04
  in
• 13:04
  almost
• 13:05
  all
• 13:05
  of
• 13:05
  your
• 13:05
  board
• 13:05
  questions.
• 13:06
  Unless
• 13:07
  your
• 13:07
  patient
• 13:07
  is
• 13:08
  like
• 13:08
  exhibiting
• 13:08
  signs
• 13:09
  of
• 13:10
  like
• 13:10
  an
• 13:11
  severe
• 13:12
  distress,
• 13:13
  maybe
• 13:13
  from
• 13:13
  serotonin
• 13:14
  syndrome
• 13:14
  or
• 13:14
  lithium
• 13:15
  toxicity.
• 13:16
  And
• 13:16
  of
• 13:16
  course
• 13:17
  there's
• 13:17
  always
• 13:17
  like
• 13:17
  protocols
• 13:18
  to
• 13:19
  taper
• 13:19
  or
• 13:20
  remove
• 13:20
  the
• 13:20
  met,
• 13:20
  depending
• 13:21
  on
• 13:21
  the
• 13:21
  clinical
• 13:21
  circumstance.
• 13:22
  But
• 13:23
  that
• 13:23
  would
• 13:23
  be
• 13:23
  a
• 13:24
  very
• 13:24
  rash
• 13:24
  thing
• 13:24
  to
• 13:25
  do
• 13:25
  in
• 13:25
  this
• 13:25
  case
• 13:25
  and
• 13:26
  it's
• 13:26
  not,
• 13:26
  it's
• 13:26
  not
• 13:27
  the
• 13:27
  right
• 13:27
  answer.
• 13:27
  Now
• 13:28
  option,
• 13:29
  option
• 13:29
  A,
• 13:30
  A,
• 13:30
  discontinuing
• 13:31
  Wellbutrin
• 13:32
  due
• 13:32
  to
• 13:32
  concern
• 13:32
  for
• 13:32
  stimulant
• 13:33
  misuse,
• 13:33
  potentiating
• 13:34
  seizure
• 13:34
  risk.
• 13:35
  Okay.
• 13:36
  Yeah,
• 13:36
  you
• 13:36
  crush
• 13:36
  up
• 13:36
  your
• 13:36
  Wellbutrin,
• 13:37
  I
• 13:37
  guess
• 13:38
  that's
• 13:38
  been
• 13:38
  done
• 13:38
  in
• 13:38
  certain
• 13:39
  prison
• 13:39
  settings.
• 13:39
  You
• 13:40
  snort
• 13:40
  it,
• 13:40
  you
• 13:41
  could
• 13:41
  potentially
• 13:41
  potentiate
• 13:42
  a
• 13:42
  seizure.
• 13:43
  But
• 13:43
  there's
• 13:44
  again,
• 13:44
  there's
• 13:44
  just
• 13:44
  really
• 13:44
  no
• 13:45
  evidence
• 13:45
  for
• 13:45
  you
• 13:45
  to
• 13:46
  jump
• 13:46
  to
• 13:46
  that
• 13:46
  conclusion
• 13:47
  so
• 13:47
  quickly.
• 13:48
  She
• 13:48
  hasn't
• 13:48
  endorsed
• 13:49
  that.
• 13:49
  If
• 13:50
  anything,
• 13:50
  she's
• 13:50
  endorsing
• 13:51
  the
• 13:51
  opposite
• 13:51
  of
• 13:51
  that.
• 13:52
  And
• 13:52
  this
• 13:52
  is
• 13:52
  just
• 13:53
  again
• 13:53
  kind
• 13:53
  of
• 13:53
  rash
• 13:54
  and,
• 13:55
  and
• 13:55
  ridiculous
• 13:56
  to
• 13:56
  just
• 13:56
  knock
• 13:57
  her
• 13:57
  off
• 13:57
  a
• 13:57
  med
• 13:57
  that
• 13:57
  has
• 13:58
  been
• 13:58
  working.
• 13:58
  It's
• 13:59
  not
• 13:59
  the
• 13:59
  right
• 13:59
  next
• 14:00
  step.
• 14:00
  Right.
• 14:01
  I
• 14:01
  would
• 14:01
  argue
• 14:01
  also
• 14:01
  that
• 14:02
  the
• 14:02
  bupropion
• 14:03
  is,
• 14:03
  it's
• 14:03
  a
• 14:04
  dose
• 14:04
  dependent
• 14:04
  risk
• 14:04
  for
• 14:04
  seizures.
• 14:05
  Definitely
• 14:05
  a
• 14:06
  much
• 14:06
  higher
• 14:06
  risk
• 14:07
  the
• 14:07
  higher
• 14:07
  you
• 14:07
  go
• 14:08
  on
• 14:08
  it,
• 14:08
  but
• 14:09
  it's
• 14:09
  still
• 14:09
  kind
• 14:09
  of
• 14:09
  an
• 14:09
  absolute
• 14:10
  low
• 14:10
  risk.
• 14:11
  And
• 14:11
  there's
• 14:12
  no
• 14:12
  eating
• 14:13
  disorder
• 14:13
  history
• 14:14
  that
• 14:14
  we've
• 14:14
  confirmed
• 14:14
  here.
• 14:15
  There's
• 14:15
  no
• 14:15
  past
• 14:15
  history
• 14:16
  of
• 14:16
  seizures
• 14:16
  here
• 14:16
  either.
• 14:17
  That
• 14:17
  would
• 14:17
  elevate
• 14:17
  her
• 14:18
  risk.
• 14:18
  So
• 14:18
  I
• 14:18
  just
• 14:19
  don't,
• 14:19
  I'm
• 14:19
  not
• 14:19
  comfortable
• 14:19
  with
• 14:20
  that
• 14:20
  answer
• 14:20
  either
• 14:20
  based
• 14:21
  on
• 14:21
  this
• 14:21
  question.
• 14:22
  Now
• 14:22
  I
• 14:23
  think
• 14:23
  you'd
• 14:24
  be
• 14:24
  very
• 14:24
  wise
• 14:24
  if
• 14:25
  your
• 14:25
  guesses
• 14:26
  kind
• 14:26
  of
• 14:26
  boil
• 14:27
  down
• 14:27
  to
• 14:27
  options
• 14:27
  D
• 14:28
  and
• 14:28
  options
• 14:28
  E.
• 14:29
  And
• 14:29
  option
• 14:30
  D
• 14:30
  again
• 14:30
  is
• 14:30
  reassure
• 14:31
  the
• 14:31
  patient
• 14:31
  that
• 14:31
  her
• 14:32
  current
• 14:32
  medications
• 14:32
  are
• 14:32
  the
• 14:33
  most
• 14:33
  likely
• 14:33
  explanation
• 14:34
  for
• 14:34
  these
• 14:34
  false
• 14:34
  positive
• 14:35
  results
• 14:35
  and
• 14:36
  order
• 14:36
  confirmatory
• 14:37
  testing
• 14:37
  before
• 14:37
  any
• 14:38
  changes.
• 14:38
  Option
• 14:39
  E
• 14:40
  is
• 14:40
  repeating
• 14:40
  the
• 14:41
  immunoassay
• 14:41
  in
• 14:41
  two
• 14:42
  weeks
• 14:43
  to
• 14:43
  see
• 14:43
  if
• 14:43
  the
• 14:43
  results
• 14:44
  are
• 14:44
  consistent
• 14:45
  before
• 14:45
  taking
• 14:46
  further
• 14:46
  action.
• 14:47
  Okay,
• 14:48
  Both
• 14:48
  of
• 14:48
  these
• 14:49
  may
• 14:49
  sound
• 14:49
  reasonable,
• 14:50
  but
• 14:50
  I
• 14:50
  will
• 14:50
  tell
• 14:51
  you
• 14:51
  the
• 14:51
  answer
• 14:51
  is
• 14:51
  not
• 14:52
  E.
• 14:53
  Repeating
• 14:53
  the
• 14:53
  immunoassay
• 14:55
  may
• 14:55
  sound
• 14:55
  the
• 14:56
  most
• 14:56
  reasonable.
• 14:56
  Like,
• 14:56
  let's
• 14:57
  just
• 14:57
  recheck
• 14:57
  this.
• 14:58
  But
• 14:58
  you're
• 14:58
  still
• 14:58
  going
• 14:58
  to
• 14:59
  get
• 14:59
  the
• 14:59
  same
• 14:59
  false
• 14:59
  positive
• 15:00
  result
• 15:01
  because
• 15:01
  the
• 15:01
  patient
• 15:01
  is
• 15:01
  still
• 15:02
  taking
• 15:02
  the
• 15:02
  same
• 15:02
  medications
• 15:03
  that
• 15:03
  can
• 15:03
  reliably
• 15:04
  produce
• 15:05
  these
• 15:05
  false
• 15:05
  positive
• 15:06
  results,
• 15:06
  and
• 15:07
  it
• 15:07
  kind
• 15:07
  of
• 15:07
  delays
• 15:07
  the
• 15:08
  resolution.
• 15:08
  It
• 15:09
  might
• 15:09
  prolong
• 15:09
  her
• 15:09
  distress.
• 15:10
  Now
• 15:10
  she's
• 15:10
  waiting
• 15:10
  in
• 15:11
  limbo
• 15:11
  for
• 15:11
  two
• 15:11
  weeks
• 15:12
  wondering
• 15:12
  what's
• 15:12
  going
• 15:12
  to
• 15:13
  happen
• 15:13
  with
• 15:13
  her
• 15:13
  treatment
• 15:13
  plan,
• 15:14
  whether
• 15:14
  she's
• 15:14
  going
• 15:14
  to
• 15:15
  be
• 15:15
  like,
• 15:15
  labeled
• 15:16
  perpetually
• 15:17
  as
• 15:17
  in
• 15:18
  her
• 15:18
  chart,
• 15:18
  as
• 15:18
  someone
• 15:19
  who's
• 15:19
  potentially
• 15:19
  addicted
• 15:20
  to
• 15:21
  a
• 15:21
  medication
• 15:22
  or
• 15:22
  diverting
• 15:22
  substances
• 15:23
  that
• 15:24
  could
• 15:24
  affect
• 15:24
  her
• 15:24
  insurance
• 15:25
  coverage,
• 15:25
  it
• 15:25
  could
• 15:25
  affect
• 15:26
  her,
• 15:26
  you
• 15:26
  know,
• 15:26
  future
• 15:27
  treatment
• 15:27
  and
• 15:28
  stigma
• 15:28
  and
• 15:29
  her
• 15:29
  just
• 15:29
  general
• 15:29
  approach
• 15:30
  with
• 15:30
  providers
• 15:30
  and
• 15:30
  their
• 15:30
  approach
• 15:31
  to
• 15:31
  her.
• 15:32
  So
• 15:32
  repeating
• 15:33
  this
• 15:33
  in
• 15:33
  two
• 15:33
  weeks
• 15:34
  will
• 15:34
  not
• 15:34
  really
• 15:34
  help.
• 15:35
  We
• 15:35
  actually
• 15:36
  need
• 15:37
  option
• 15:38
  D.
• 15:38
  Option
• 15:39
  D,
• 15:39
  we
• 15:39
  need
• 15:40
  a
• 15:40
  confirmatory
• 15:40
  test.
• 15:41
  Okay.
• 15:42
  And
• 15:42
  it
• 15:42
  is
• 15:43
  true
• 15:43
  that
• 15:43
  bupropion
• 15:44
  is
• 15:44
  one
• 15:44
  of
• 15:45
  the
• 15:45
  most
• 15:45
  common
• 15:45
  causes
• 15:46
  of
• 15:46
  false
• 15:46
  positive
• 15:46
  amphetamine
• 15:47
  immunoassays.
• 15:48
  Okay.
• 15:49
  So
• 15:49
  up
• 15:49
  to
• 15:49
  4
• 15:50
  to
• 15:50
  10%
• 15:51
  across
• 15:51
  platforms.
• 15:52
  Reportedly,
• 15:53
  the
• 15:53
  evidence
• 15:53
  shows
• 15:54
  4
• 15:54
  to
• 15:54
  10%
• 15:56
  false
• 15:56
  positive
• 15:57
  rate
• 15:57
  with
• 15:57
  Wellbutrin
• 15:58
  for
• 15:58
  amphetamine.
• 15:59
  So
• 15:59
  it's
• 15:59
  probably
• 15:59
  her
• 16:00
  Wellbutrin
• 16:00
  that's
• 16:01
  making
• 16:01
  you
• 16:01
  think
• 16:01
  that
• 16:01
  she's
• 16:02
  abusing
• 16:02
  amphetamines
• 16:03
  on
• 16:03
  the
• 16:03
  side.
• 16:03
  And
• 16:04
  then
• 16:04
  trazodone
• 16:05
  can
• 16:05
  cause
• 16:05
  false
• 16:05
  positive
• 16:06
  benzodiazepine
• 16:07
  results
• 16:08
  due
• 16:08
  to
• 16:08
  its
• 16:08
  metabolite.
• 16:09
  Okay,
• 16:11
  so
• 16:11
  we
• 16:11
  don't
• 16:11
  need
• 16:11
  to
• 16:11
  change
• 16:12
  meds,
• 16:12
  we
• 16:12
  don't
• 16:12
  need
• 16:13
  referrals,
• 16:13
  we
• 16:13
  don't
• 16:13
  need
• 16:13
  to
• 16:14
  withhold
• 16:14
  prescriptions.
• 16:15
  We
• 16:15
  need
• 16:15
  confirmatory
• 16:16
  testing,
• 16:17
  and
• 16:17
  that's
• 16:18
  GCTAC
• 16:19
  ms,
• 16:20
  gas
• 16:21
  chromatography,
• 16:22
  mass
• 16:22
  spectrometry.
• 16:23
  But
• 16:24
  liquid
• 16:24
  chromatography.
• 16:25
  Right.
• 16:25
  LC
• 16:26
  Ms.
• 16:27
  Mass
• 16:27
  spectrometry.
• 16:28
  Those,
• 16:29
  those
• 16:30
  that
• 16:30
  verbiage.
• 16:30
  Just
• 16:31
  get
• 16:31
  familiar
• 16:31
  with
• 16:31
  that.
• 16:32
  That's
• 16:32
  basically
• 16:33
  a
• 16:33
  fancy
• 16:33
  schmancy
• 16:34
  technique
• 16:34
  where
• 16:35
  the
• 16:35
  sample
• 16:35
  gets
• 16:35
  vaporized
• 16:36
  into
• 16:36
  a
• 16:36
  gas,
• 16:37
  passed
• 16:37
  through
• 16:37
  a
• 16:37
  column,
• 16:38
  kind
• 16:38
  of
• 16:38
  separating
• 16:39
  its
• 16:39
  components,
• 16:39
  which
• 16:40
  are
• 16:40
  then
• 16:40
  identified
• 16:41
  by
• 16:41
  their
• 16:41
  unique
• 16:42
  mass
• 16:42
  fingerprint.
• 16:43
  Okay,
• 16:44
  I'm
• 16:44
  sorry
• 16:44
  I
• 16:44
  cluttered
• 16:45
  your
• 16:45
  brain
• 16:45
  with
• 16:45
  it.
• 16:45
  But
• 16:46
  the
• 16:46
  bigger
• 16:46
  picture
• 16:47
  is
• 16:47
  that
• 16:47
  these
• 16:47
  immunoassays
• 16:48
  can
• 16:48
  be
• 16:49
  wrong
• 16:49
  consistently.
• 16:50
  And
• 16:50
  we're
• 16:50
  going
• 16:50
  to
• 16:50
  do
• 16:50
  a
• 16:50
  whole
• 16:51
  episode
• 16:51
  on
• 16:51
  that,
• 16:51
  actually,
• 16:52
  because
• 16:52
  they
• 16:52
  can
• 16:53
  have
• 16:53
  significant
• 16:54
  treatment
• 16:54
  implications
• 16:55
  for
• 16:55
  involved.
• 16:56
  And,
• 16:57
  and
• 16:57
  so,
• 16:57
  and
• 16:57
  we'll
• 16:58
  actually,
• 16:58
  if
• 16:58
  you
• 16:59
  become
• 16:59
  a
• 16:59
  Patreon
• 16:59
  member,
• 17:00
  you'll
• 17:00
  get
• 17:01
  a
• 17:01
  really
• 17:01
  Thorough
• 17:02
  list
• 17:02
  of
• 17:03
  the
• 17:03
  frequent
• 17:04
  culprits
• 17:04
  here
• 17:05
  that
• 17:05
  you
• 17:05
  need
• 17:05
  to
• 17:05
  watch
• 17:06
  out
• 17:06
  for.
• 17:06
  In
• 17:06
  psychiatry
• 17:07
  in
• 17:07
  particular,
• 17:07
  Patreon
• 17:08
  is
• 17:08
  ideal
• 17:09
  if
• 17:09
  you
• 17:10
  want
• 17:10
  to
• 17:10
  not
• 17:10
  just
• 17:11
  be
• 17:11
  a
• 17:11
  prescriber
• 17:12
  who
• 17:12
  follows
• 17:13
  algorithms
• 17:14
  and
• 17:14
  hands
• 17:14
  out
• 17:15
  medications,
• 17:15
  but
• 17:15
  a
• 17:16
  prescriber
• 17:16
  who
• 17:17
  really
• 17:17
  understands
• 17:18
  the
• 17:18
  how
• 17:18
  and
• 17:18
  the
• 17:19
  why
• 17:19
  and
• 17:19
  the
• 17:19
  context
• 17:20
  behind
• 17:20
  what
• 17:20
  you're
• 17:20
  doing.
• 17:21
  That
• 17:21
  is
• 17:21
  why
• 17:21
  we
• 17:21
  built
• 17:22
  Patreon.
• 17:23
  Patients
• 17:23
  can
• 17:23
  smell
• 17:24
  you
• 17:24
  a
• 17:24
  mile
• 17:24
  away
• 17:25
  when
• 17:25
  you're
• 17:25
  just
• 17:26
  following
• 17:26
  the
• 17:27
  algos
• 17:27
  and
• 17:27
  you
• 17:27
  don't
• 17:28
  know
• 17:28
  the
• 17:28
  how
• 17:28
  and
• 17:28
  why.
• 17:29
  Right.
• 17:29
  And
• 17:30
  so
• 17:30
  we
• 17:30
  really
• 17:30
  want
• 17:30
  to
• 17:30
  prepare
• 17:31
  you
• 17:31
  and
• 17:31
  prepare
• 17:32
  each
• 17:32
  other
• 17:32
  in
• 17:32
  our
• 17:32
  Patreon
• 17:33
  community.
• 17:33
  It's
• 17:33
  well
• 17:34
  worth
• 17:34
  the
• 17:34
  membership.
• 17:35
  Highly
• 17:35
  recommend
• 17:36
  you
• 17:36
  go
• 17:36
  to
• 17:36
  our
• 17:36
  show
• 17:36
  notes
• 17:37
  and
• 17:37
  become
• 17:37
  a
• 17:37
  member.
• 17:38
  And
• 17:38
  you
• 17:38
  will
• 17:38
  get
• 17:38
  these
• 17:39
  fancy
• 17:39
  schmancy
• 17:40
  breakdowns.
• 17:40
  Really
• 17:41
  fun
• 17:41
  to
• 17:41
  study
• 17:42
  and
• 17:42
  keep
• 17:42
  at
• 17:42
  the
• 17:42
  top
• 17:43
  of
• 17:43
  your
• 17:43
  game.
• 17:43
  Just
• 17:43
  the
• 17:44
  materials
• 17:44
  we
• 17:44
  have
• 17:44
  there,
• 17:45
  the
• 17:45
  community
• 17:45
  we're
• 17:45
  building.
• 17:46
  We
• 17:46
  want
• 17:47
  to
• 17:47
  get
• 17:47
  a
• 17:48
  confirmatory
• 17:48
  test
• 17:49
  here.
• 17:49
  And
• 17:49
  there's
• 17:50
  a
• 17:50
  sophisticated
• 17:51
  way
• 17:51
  to
• 17:51
  do
• 17:51
  that
• 17:52
  that
• 17:52
  all
• 17:52
  of
• 17:52
  your
• 17:53
  clinics
• 17:53
  should
• 17:53
  have
• 17:53
  access
• 17:54
  to
• 17:54
  the
• 17:55
  GC
• 17:55
  Ms.
• 17:56
  Mass
• 17:57
  spectrometry.
• 17:59
  That's
• 17:59
  what
• 17:59
  we
• 17:59
  need
• 17:59
  to
• 17:59
  do.
• 18:00
  And
• 18:00
  we
• 18:01
  might
• 18:01
  find,
• 18:02
  lo
• 18:02
  and
• 18:02
  behold,
• 18:02
  that
• 18:03
  it's
• 18:03
  actually
• 18:03
  negative,
• 18:04
  negative
• 18:04
  for
• 18:04
  benzos,
• 18:05
  negative
• 18:05
  for
• 18:05
  amphetamines.
• 18:06
  We're
• 18:06
  so
• 18:07
  sorry,
• 18:07
  Bonnie.
• 18:08
  We
• 18:08
  never
• 18:08
  meant
• 18:08
  to
• 18:09
  falsely
• 18:10
  accuse
• 18:10
  you
• 18:10
  of
• 18:10
  anything.
• 18:11
  Now
• 18:11
  that
• 18:12
  we
• 18:12
  have
• 18:12
  this
• 18:12
  knowledge,
• 18:12
  that's
• 18:13
  when
• 18:13
  we
• 18:13
  can
• 18:13
  have
• 18:13
  a
• 18:13
  really
• 18:14
  compassionate
• 18:14
  conversation
• 18:15
  with
• 18:15
  Bonnie
• 18:16
  and
• 18:16
  say,
• 18:16
  Bonnie,
• 18:16
  you
• 18:16
  know,
• 18:17
  a
• 18:17
  lot
• 18:18
  of
• 18:18
  times
• 18:18
  the
• 18:18
  medications
• 18:19
  we
• 18:19
  take
• 18:19
  in
• 18:19
  psychiatry
• 18:20
  will
• 18:20
  produce
• 18:21
  false
• 18:22
  positive
• 18:22
  results.
• 18:24
  So
• 18:24
  we
• 18:24
  owe
• 18:24
  it
• 18:24
  to
• 18:25
  you
• 18:25
  to
• 18:26
  get
• 18:27
  a
• 18:28
  second
• 18:28
  test
• 18:28
  on
• 18:29
  this.
• 18:29
  And
• 18:29
  we
• 18:29
  do
• 18:29
  that
• 18:30
  just
• 18:30
  to
• 18:30
  keep
• 18:30
  everybody
• 18:31
  safe
• 18:31
  and
• 18:31
  transparent.
• 18:32
  We're
• 18:32
  just
• 18:33
  going
• 18:33
  to
• 18:33
  do
• 18:33
  this
• 18:33
  as
• 18:33
  a
• 18:33
  routine
• 18:34
  procedure
• 18:35
  and
• 18:35
  we're
• 18:35
  going
• 18:35
  to
• 18:35
  continue
• 18:36
  your
• 18:36
  medications.
• 18:36
  And
• 18:37
  we're
• 18:37
  so
• 18:37
  glad
• 18:37
  they've
• 18:37
  been
• 18:38
  helping
• 18:38
  you
• 18:38
  and
• 18:39
  we'll
• 18:39
  let
• 18:39
  you
• 18:39
  know
• 18:39
  when
• 18:39
  the
• 18:40
  results
• 18:40
  come
• 18:40
  out.
• 18:41
  But
• 18:41
  again,
• 18:42
  it's
• 18:42
  standard
• 18:42
  protocol.
• 18:43
  And
• 18:44
  your
• 18:44
  trazodone
• 18:45
  and
• 18:46
  your
• 18:46
  bupropion
• 18:47
  can
• 18:47
  absolutely
• 18:48
  cause
• 18:49
  these
• 18:50
  false
• 18:51
  positives.
• 18:53
  And
• 18:53
  because
• 18:53
  you're
• 18:53
  aware
• 18:54
  of
• 18:54
  the
• 18:54
  false
• 18:55
  positives,
• 18:56
  you're
• 18:56
  able
• 18:56
  to
• 18:56
  reassure
• 18:57
  her.
• 18:57
  See,
• 18:57
  if
• 18:57
  we're
• 18:57
  not
• 18:57
  aware
• 18:58
  of
• 18:58
  these
• 18:58
  false
• 18:58
  positives,
• 18:59
  we
• 18:59
  could
• 19:00
  be
• 19:00
  much
• 19:00
  more
• 19:00
  quick
• 19:01
  to
• 19:01
  judge
• 19:02
  and
• 19:02
  to
• 19:03
  potentially
• 19:03
  put
• 19:03
  in
• 19:03
  a
• 19:04
  referral
• 19:04
  in
• 19:04
  an
• 19:04
  inappropriate
• 19:05
  to
• 19:05
  an
• 19:05
  inappropriate
• 19:06
  provider.
• 19:07
  Right?
• 19:08
  It's
• 19:08
  like
• 19:08
  now
• 19:08
  this
• 19:08
  patient
• 19:09
  who's
• 19:09
  recovering
• 19:10
  from
• 19:10
  PTSD
• 19:11
  and
• 19:11
  depression
• 19:12
  is
• 19:12
  being
• 19:13
  suspected
• 19:14
  of
• 19:14
  abusing
• 19:14
  and
• 19:14
  diverting
• 19:15
  her
• 19:15
  meds.
• 19:16
  And
• 19:16
  now
• 19:16
  she's
• 19:17
  at
• 19:17
  a
• 19:17
  substance
• 19:17
  use
• 19:17
  clinic
• 19:18
  and
• 19:18
  nobody
• 19:18
  believes
• 19:18
  her.
• 19:19
  And
• 19:19
  now
• 19:19
  she
• 19:19
  has
• 19:19
  all
• 19:19
  kinds
• 19:20
  of
• 19:20
  medical.
• 19:21
  Medical
• 19:21
  trauma
• 19:22
  or,
• 19:22
  or,
• 19:22
  you
• 19:22
  know,
• 19:23
  medical
• 19:23
  concerns.
• 19:23
  She's
• 19:24
  very
• 19:24
  reluctant
• 19:25
  to
• 19:25
  approach
• 19:25
  providers
• 19:26
  again.
• 19:26
  And
• 19:26
  this
• 19:27
  can
• 19:27
  really
• 19:27
  damage
• 19:27
  patients,
• 19:28
  right?
• 19:28
  This
• 19:28
  could
• 19:28
  really
• 19:29
  hurt
• 19:29
  them,
• 19:29
  especially
• 19:30
  if
• 19:30
  we
• 19:30
  withhold
• 19:31
  any
• 19:31
  scripts
• 19:32
  or
• 19:32
  anything.
• 19:33
  So,
• 19:33
  big
• 19:33
  takeaway,
• 19:34
  my
• 19:34
  friends,
• 19:34
  going
• 19:35
  into
• 19:35
  boards.
• 19:35
  Just
• 19:36
  even
• 19:36
  if
• 19:36
  you're
• 19:36
  a
• 19:36
  practicing
• 19:37
  clinician,
• 19:37
  you're
• 19:37
  a
• 19:37
  pa,
• 19:38
  you're
• 19:39
  family
• 19:39
  med
• 19:39
  doc,
• 19:40
  knowing
• 19:40
  the
• 19:40
  false
• 19:41
  positives,
• 19:42
  false
• 19:42
  negatives,
• 19:43
  all
• 19:43
  of
• 19:43
  that.
• 19:44
  And
• 19:44
  we're
• 19:44
  going
• 19:44
  to
• 19:44
  have
• 19:44
  a
• 19:44
  big
• 19:45
  beefy
• 19:45
  episode
• 19:46
  on
• 19:46
  all
• 19:46
  of
• 19:46
  those
• 19:46
  issues
• 19:47
  shortly.
• 19:48
  That,
• 19:48
  and
• 19:48
  if
• 19:48
  you're
• 19:48
  a
• 19:49
  Patreon
• 19:49
  member,
• 19:49
  you
• 19:49
  can
• 19:50
  have
• 19:50
  access
• 19:50
  to
• 19:50
  that
• 19:50
  early
• 19:51
  episode
• 19:51
  drop,
• 19:52
  because
• 19:52
  this,
• 19:52
  this
• 19:53
  is
• 19:53
  super
• 19:53
  important
• 19:53
  stuff.
• 19:54
  Well,
• 19:54
  thank
• 19:54
  you
• 19:54
  for
• 19:54
  tuning
• 19:55
  in
• 19:55
  to
• 19:55
  another
• 19:55
  episode
• 19:56
  of
• 19:56
  Pearls
• 19:56
  and
• 19:57
  Prep
• 19:57
  Take.